Care of the Post-Cardiac Surgery Patient. Lundy J. Campbell, M.D. Associate Professor University of California

Transcription

1 Care of the Post-Cardiac Surgery Patient Lundy J. Campbell, M.D. Associate Professor University of California

2 Post-Operative Issues Post-op atrial fibrillation Acute kidney injury Acute respiratory failure Post-operative glycemic control Deep sternal wound infection Blood transfusion Stroke

3 Post-Operative Issues Post-op atrial fibrillation Acute kidney injury Acute respiratory failure Post-operative glycemic control Deep sternal wound infection Blood transfusion Stroke

4 Atrial Fibrillation Post-op incidence Historically CABG 11-40% All CT 10-65% Increasing incidence with increasing age 24% increasing frequency with each add l 5 yr Initially thought to be more of a nuisance Long-term morbidity/mortality?

5 Atrial Fibrillation After Isolated Coronary Surgery Affects Late Survival 1832 patient prospective observational study No history of permanent afib prior to surgery Patient management and anesthesia technique standardized 31% patients developed afib post op Longer hospital LOS Increased hospital and long-term mortality Adjusted hazard ratio for afib 2.13 based on propensity scoring Mariscalco, et al. Circulation 2008;118;

6 Kaplan-Meier survival estimates according to the occurrence of postoperative AF Mariscalco, G. et al. Circulation 2008;118: Copyright 2008 American Heart Association

7 New Onset A-Fib After Isolated CABG and Long-Term Survival Single-center, retrospective observational study of 6899 consecutive patients without pre-op a-fib 26% developed a-fib post-op 10 year unadjusted survival: 52.3% with post-op a-fib 69.4% no post-op a-fib Risk adjusted to STS mortality risk factors HTN, CHF, PVD, DM, EF, IABP, resp failure, etc Afib increased risk of adjusted mortality by 29% Filardo, G. et al. Circ Cardiovasc Qual Outcomes 2009;2:

8 Effect of new-onset postoperative AFIB on survival in CABG surgery patients Filardo, G. et al. Circ Cardiovasc Qual Outcomes 2009;2: Copyright 2009 American Heart Association

9 New Onset A-fib and Long-Term Mortality After CABG Single center, retrospective observational study of 16,169 consecutive CABG patients OPCABG in 41.5% of patients Propensity adjusted to STS risk factors Post-operative a-fib occurred in 18.5% of patients Chami, et al. JACC Vol 55, no 13, 2010:1370-6

10 New Onset A-fib and Long-Term Adjusted HR 1.21 Mortality After CABG At 1 yr: 96.3% vs 90.1% survival At 10 yrs: 70.2% vs 55.2% survival Only 20.5% of patients in a-fib discharged with warfarin Patients in a-fib less likely to get betablocker, statin or anti-platelet therapy Adjusting for warfarin: HR % relative reduction in mortality Chami, et al. JACC Vol 55, no 13, 2010:1370-6

11 Adjusted Kaplan-Meier Survival Curves Chami, et al. JACC Vol 55, no 13, 2010:1370-6

12 Post-Operative Atrial Fibrillation Increased short and long term mortality Increased with age and severity of illness Warfarin, betablockade, amiodarone, atrial pacing shown to be protective Likely no difference in CABG or OPCABG

13 Acute Renal Failure Studies of renal failure post-ct surgery limited by lack of uniform ARF (AKI) definition. Historical risk of ARF post CT-surgery 5-31% depending on criteria Up to 30% of CT surgery patients develop clinically important renal failure 1-2% require dialysis Conveys approx 8-fold increase risk of death

14 ARF Incidence Large prospective, cohort study (>43,000) VA patients undergoing CT surgery ARF defined as >50% increase in serum Cr from baseline Risk of ARF req dialysis 1.1% 0.9% CABG and 2.0% valve 63.7% mortality in pts with ARF requiring dialysis vs 4.3% in pts without Chertow, G. M. et al. Circulation 1997;95:

15 Risk of acute renal failure with increasing age Chertow, G. M. et al. Circulation 1997;95: Copyright 1997 American Heart Association

16 ARF Post-CABG Mortality Canadian multicenter 3500 pt retospective study. All on pump Patients divided into quartiles 25% decrease in GFR > 25% decrease in GFR (24%) 4 fold increased risk of death > 50% decrease in GFR (7%) 5.9 fold increased risk of death > 75% decrease in GFR (3%) 9.5 fold increased risk of death Karkouti, K. et al. Circulation 2009;119:

17 Risk Factors of Post-Op ARF Duration of CPB Pre-operative use of IABP Pre-operative anemia Pre-operative RBC transfusions Post-operative re-operation Karkouti, K. et al. Circulation 2009;119:

18 Probability of AKI (>50% decrease in egfr or dialysis) Karkouti, K. et al. Circulation 2009;119: Copyright 2009 American Heart Association

19 Pathogenesis of Post-Op Renal Failure Normal autoregulation Normal GFR maintained until MAP<80 Typically MAP<80 on CPB Impaired autoregulation Age, HTN, CRI, atherosclerosis Drugs ACE-I, NSAID, ARB, contrast agents Pro-inflammatory state Operative trauma, reperfusion injury, blood contact with CPB circuit

20 Recent Trends in ARF Mortality Nationwide database CABG patients Estimated 7,339,520 CABG procedures 0.4% patients developed ARF-D ARF-D incidence increased over time 0.22% in 1988 to 0.57% in 2003 Decline in ARF-D mortality over same period 47.4% in 1988 to 29.7% in 2003 Nicoara et al. Blood Purif 2009;28:

21 AKI and OPCABG Meta analysis of 6 RCTs and 16 observational studies Comparing On-Pump CABG with OPCABG Overall found decreased risk in OPCABG (OR 0.57) No difference in AKI requiring dialysis No uniform definition of AKI between studies Am J Kidney Dis 2009;54:

22 Overall Acute Kidney Injury Am J Kidney Dis 2009;54:

23 Acute Kidney Requiring Dialysis Am J Kidney Dis 2009;54:

24 Deep Sternal Wound Infection Historical incidence between 1-3% Reported mortality up to 20% Retrospective study of 3760 consecutive CABG patients from % developed DSWI Predictors DM (OR 5.5) Pre-op hemodynamic instability (OR 3.4) Pre-op renal failure (OR 2.6) Sepsis and/or endocarditis (OR 29.9) Toumpoulis I K et al. Chest 2005;127:

25 Deep Sternal Wound Infection No difference in early mortality Large difference in long-term mortality 1 yr: 93.6 vs 66.2% 5 yrs: 82.3 vs 50.8% 10 yrs 67.3 vs 40.6% Toumpoulis I K et al. Chest 2005;127:

26 Blood Transfusions Association with ARF Association with respiratory failure Association with infections Deep sternal wound infection STS reportable data Are there specific factors important in the CT surgical patient?

27 Age of RBC s Important Decreased deformability Decreased ATP Decreased 2,3 DPG Decreased NO generation Increased adhesion to vascular endothelium

28 Duration of RBC Storage Hypothesis: Older blood worse By FDA: Can transfuse up to 42 days Single-center randomized prospective study 2872 pts got new (<14 days old) blood 3130 pts got old (>14 days old) blood Median storage 11 days in newer arm 20 days in older arm Koch C et al. N Engl J Med 2008;358:

29 Duration of RBC Storage Standard surgical / anesthesia pracitice All patients done on CPB Increased mortality with older blood In hospital: 2.8 vs 1.4% 1 yr: 11 vs 7.4% (NNT 28) Increased morbidity with older blood Intubation > 72 hours: 9.7 vs 5.6% Renal Failure: 2.7 vs 1.6% Sepsis: 4 vs 2.8% Koch C et al. N Engl J Med 2008;358:

30 Kaplan-Meier Estimates of Survival and Death Koch C et al. N Engl J Med 2008;358:

31 Number of Red-Cell Units Transfused in Relation to the Percentage of Patients Receiving Transfusion Koch C et al. N Engl J Med 2008;358:

32 Stroke Incidence approximately 1-2% Multiple associated risk factors Carotid stenosis Prior stroke history Valve surgery Re-do heart surgery Duration of pump time Diabetes Aortic atherosclerosis Recent MI Age > 75 years Low CO Mod/severe LV dysfx HTN CRI Stamou, S. C. et al. Stroke 2001;32:

33 Independent predictors of postoperative stroke after CABG Copyright 2001 American Heart Association Stamou, S. C. et al. Stroke 2001;32:

34 OP-CABG and Stroke Meta-analysis of 41 RCTs comparing offpump and on-pump CABG with stroke risk No difference in mortality on vs off pump Off-pump technique: 50% relaive risk reduction in stroke 30% relative risk reduction in risk of afib 48% relative risk reduction in wound infection Significant increased risk of reintervention (RR1.9) Sedrakyan, A. et al. Stroke 2006;37:

35 Stroke reported in the trials of off-pump surgery Sedrakyan, A. et al. Stroke 2006;37: Copyright 2006 American Heart Association

36 Clinical outcomes in the trials of off-pump surgery Sedrakyan, A. et al. Stroke 2006;37: Copyright 2006 American Heart Association

37 OP-CABG vs On-Pump CABG 2203 VA patients at 18 med centers randomly assigned to on or off-pump CABG Primary short-term endpoint: composite of death or complications Reoperation, new mechanical support, cardiac arrest, coma, stroke, renal failure Primary long-term endpoint: composite of death or: Repeat revascularization procedure, non-fatal MI Shroyer A et al. N Engl J Med 2009;361:

38 Results No significant difference in 30 day composite outcome No difference in overall survival between 2 groups Worse long-term composite outcome for offpump than on-pump patients (9.9 vs 7.4%) Higher proportion of patients with fewer grafts than originally planned with off-pump technique 17.8 vs 11.1% Shroyer A et al. N Engl J Med 2009;361:

39 Kaplan-Meier Estimates of Survival after Surgery Shroyer A et al. N Engl J Med 2009;361:

40 Summary CT surgery patients at high risk for post-op morbidity and mortality Atrial fibrillation Long term mortality risks Treat aggressively to restore SR and anticoagulation Acute kidney injury Incidence increasing due to increasing patient age and severity of illness Overall mortality decreasing due to improved dialysis? OP-CABG benefit

41 Summary Deep sternal wound infection Associated with increased transfusions High mortality Associated with patient severity of illness Blood transfusions Minimize transfusions if possible Evidence to use newer RBCs Stroke Severe morbidity and mortality Occurs during perioperative period? Benefit with OP-CABG